Utilization Review Specialist

About the role

Oakwood Springs is a 72-bed hospital located in Oklahoma City, OK, and is part of Lifepoint Health, a diversified healthcare delivery network committed to making communities healthier® with acute care, rehabilitation, and behavioral health facilities from coast to coast.

Utilization Review Specialist

• Facilitates clinical reviews on all patient admissions and continued stays.
• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay.
• Interfaces with managed care organizations, external reviewers and other payers.
• Advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to managed care providers for necessary treatment.
• Contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay.
• Affords assistance to the treatment team in understanding the insurance company's requirements for continued stay and discharge planning.

Essential Functions

• Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services.
• Completes pre and re-certifications for inpatient and outpatient services.
• Reports appropriate denial, and authorization information to designated resource.
• Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
• Participates in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
• Works with DON to ensure documentation requirements are met.
• Sure appeals are completed thoroughly and on a timely basis.
• Interface with managed care organizations, external reviews, and other payers.
• Communicate with physicians to schedule peer to peer reviews.
• Accurately report denials.

What We Offer

• Comprehensive medical, dental, and vision plans, plus flexible-spending and health-savings accounts.
• Cashiered paid time off.
• Income-protection programs, such as life, accident, critical-injury insurance, short- and long-term disability, and identity theft coverage.
• Tuition reimbursement, loan assistance, and 401(k) matching.
• Employee assistance program including mental, physical, and financial wellness.
• Professional development and growth opportunities.

Qualifications and Requirements

• Education: Bachelor's degree required. Master's degree preferred.
• Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
• Licenses: Current unencumbered clinical license strongly preferred.
• Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred.
• May be required to work flexible hours and overtime.